Great. And once again, welcome to the Youth Running Consensus Statement, Next Steps for Research and Advocacy. I'm Dr. Brian Kraback, your moderator for today. We have a great, wonderful group of experts in youth running to explore this topic about our current consensus statement and how we can proceed to disseminate some of this information and deal with knowledge gaps in relation to youth running. So before we get started meeting our panel, our goal really today is just to figure out how can we take these youth runners and make them successful adult runners while keeping them healthy and preventing long-term injuries while promoting health throughout one's lifestyle. And why is that important? Well, we all know that exercise and activity has so many health benefits. From beginning in early childhood, there's a variety of benefits relating to both the physical, educational, and even financial. As we can see in this diagram here, the benefits are linked to decreasing obesity, decreasing the potential for heart disease, decreasing risk behavior in relation to smoking and other areas, as well as improving education, and probably most importantly that active kids become active adults. And active adults will have active kids, which is a wonderful, beautiful cycle for promoting one's overall health. And the flip side of that is that inactive people become inactive adults who have inactive kids. And in a similar fashion, we can expect issues related to overall health, increased obesity, greater stress to the system in regards to cost, heart disease, and the potential for more missed days in school, which could impact education as well. And it's pretty darn clear that we have a problem here where as kids are attempting to become active, by age 11, a high percentage of those kids are really not participating anymore in sport, which then leads to inactivity and this cycle that we're attempting to break here. So it was with this start of a framework that we started thinking about running and the fact that running is something that most people can do and get outside and utilize to get active. And so we started a conversation many years ago in regards to understanding how we can help promote youth running while attempting to minimize injury and risk in these youth runners. And what I'm about to go through is a quick walkthrough in regards to the consensus statement that was published in 2021 in the British Journal of Sports Medicine. And I would encourage all of you to go ahead and take a look at that if you have not looked at it yet. And I want to acknowledge all of the individuals who were involved in making that consensus statement, which does include all of our faculty members today. So what we did was a very detailed look at the literature to date, looking at prospective studies to try and understand what does the research show us in regards to preventing youth running injuries and illness and how that might impact overall risk factors for injury and prevention of injury, long-term health, and then a discussion about what is it appropriate and when is it appropriate for kids to start running in that regards. And what our census came paper came up with was some strong to really limited evidence in regards to what risk factors we should consider when thinking about running related injury in assessing our adolescent runners. And the focus here was on adolescent runners because the pre-adolescents and pediatric runners, there's not a lot of research there. And we're going to touch on that a little bit today. What we did find was a strong evidence in relation to such risk factors as prior injury or having the female sex, limited evidence relation to menstrual dysfunction, low body mass index, prior bone stress injury, and that we need to do more research to look at other things such as alignment, strength, foot strike patterns, running kinematics, cadence, and a variety of other factors. So with that, I would like to introduce our expert panel. All of the following individuals were involved in the developing of this consensus statement and have a wealth of knowledge in regards to the area of youth running. We have Dr. Mike Fredrickson out of Stanford, Dr. Mark Harris at University of Washington, Dr. Emily Krauss out of Stanford, and Dr. Adam Tenforty out of Harvard. And I believe all of you would be pretty aware of those individuals and ask them all to come on the screen so we can get started and get the conversation going in regards to where we're going to focus. I can see a couple there. Dr. Fredrickson, let's get you on board. And I think Dr. Harris is there as well. So thanks everyone for joining. All right. So we're going to spend about 17 or 15 to 17 minutes on each of the following areas. We're going to start off with some questions to ask our faculty members, but I would encourage any of you in the audience to chime in, in the chat and ask questions. We'll focus on three specific areas, injury risk factors and prevention, two factors that may impact long-term health, and three appropriateness of running as a sport for the pre-adolescent child. So with that, why don't we get started? And we're going to first look at this injury risk factors and prevention. And I'm going to start with Dr. Fredrickson. So we talked a little bit about some of these risk factors, strong evidence in regards to prior injury and the female sex and some limited stuff in relation to the bone stress injury, which I think is one of your areas of research as well. So in distilling this all for us, what do you think are the three probably biggest risk factors for bone stress injury? And what kind of strategy can we walk away to try and help prevent future injury? Yeah, well, thanks, Brian, for putting this together and for allowing me to be part of this. I'm really excited. But just real quickly, breaking this down, understanding that we typically talk about intrinsic risk factors and extrinsic risk factors. And so extrinsic risk factors would be things like your step rate while training, what type of shoe, your biomechanics, the terrain you're running on, your footwear, things of that nature. Interestingly, at least in terms of what's out there in the literature at this point, there isn't strong evidence for extrinsic risk factors being very, like, predominant risk factors. So what I'm going to focus on mainly are the intrinsic factors. And of those, three really jump out. One is BMI. And so your body mass in depth. So, and that goes two ways. So an increased body mass index. So above about 20 to 21 is actually associated with increased risks for medial tibial stress syndrome. And that is something you're probably going to see more in your inexperienced runner, maybe somebody who's like first time going out for cross country. It typically isn't something you're going to see with your more experienced runner. In a more experienced runner, certainly in our more elite group, what we see is that a lower BMI puts them at risk for injury. And so there was a really great, well, I wouldn't say great study, but a fascinating study for me, because I was part of it, that Dr. 1040 and I did. And we looked at 30 high schools around the Bay Area. We had almost 750 athletes and we followed them for close to two years. And what we found is that if you had a BMI that was less than 19, it puts you at a threefold risk for a bone stress injury. Additionally, the other risk factor that really stands out, again, this is intrinsic, is sex. And for what probably multiple reasons, but young women are definitely at higher risk for injury than young boys. There's a number of reasons we could probably propose about that, but the research I think still needs to be determined exactly why that is. Potentially it's biomechanical, potentially it's more related to triad, red S types of factors related to bone health, but that definitely needs further study. And then the fourth or the third big risk factor is history of previous injury. And in our study, it was interesting because we found that a previous history of fracture, and it didn't have to be a stress fracture or some type of bone stress injury, but any fracture put you at higher risk for developing a future stress fracture. So something about kids who are maybe more prone to developing fractures, maybe it's something about their bone health or their genetics does seem to be a strong risk factor there. Dr. Tenforty, you were part of that study that we'll go there. Is there anything else you want to add to that comment on that? Yeah, so I would say Dr. Fredrickson really outlined the key factors and what we have to recognize is that these are just coming from a few studies in youth runners. There's a lot we don't understand. And what's important to look at is these risk factors and understanding what might be the mechanism. So when we talk about the BMI, we looked in a separate population where we were looking at bone density values, and we're actually finding that a BMI below 17.5 appeared to be associated with a greater risk for having low bone mass for age. So BMI is kind of a messy number to look at from an absolute. There's a lot of issues with it, but more than anything, it gets down to how is the athlete fueling and are the athletes getting the appropriate lean mass to do the shock attenuation and prevent a bone injury or to have the appropriate body composition, which would suggest that they're fueling appropriately for recovery and allowing the right hormonal milieu and nutritional substrate for bones to grow stronger with sport, which is what we would anticipate a majority of athletes would see. Musculoskeletal health should improve when you do a sport, including long distance running. Now, Dr. Tanfori, we talked a little bit about how there's a focus on this adolescence, but I know you've been looking at that sort of middle school group in regards to potential risk factors. What is some of your recent research suggested? So we wanted to look a little bit more at the middle school aged athletes, and it was actually a really eager high school student who had connections with a lot of the club sports in the greater Massachusetts area. And we saw very similar trends of what we had reported in the high school cohort. We saw, I believe it was close to 7% of girls and 3.5% of boys had actually sustained one or more bone stress injury by an average age of 13. So, I mean, that's already a very high prevalence, and we're talking at a much younger age. One of the other factors that was interesting looking at bone stress injury was a family history of osteoporosis seemed to be a strong risk factor for having bone stress injury. So I think one of the comments Dr. Fredrickson made earlier about a prior fracture being a risk factor for a future bone stress injury, this for me was another kind of confirming factor, which is we need to start thinking about skeletal health at a much younger age. And we need to not just be thinking about stress fractures, but a lot of kids will fall as a result of playing sports, but not all of them will sustain a fracture as a result of trauma or overuse. So I would say those were some of the key findings that were really interesting, which is that we shouldn't just think about bone stress injuries as occurring in high school and older. We really need to think at much younger ages. One of the other really interesting factors too was one of our key initial aims that Dr. Fredrickson and I had in our high school cohort was understanding the role of ball sports in prevention of bone stress injury. And the concept is that if you perform a multidirectional high loading intermittent impact sport, as opposed to the monotonous repetitive overuse that we see in long distance running, perhaps you can lead to stronger, more fracture resistant bones. In our high school cohort, we had identified that boys that participated in basketball had an 82% reduction in risk for bone stress or for a future stress fracture. What we found in the middle school cohort is that both boys and girls, and again, this is a cohort of 2150 youth runners of average age 13, the ball sports seem to be associated with protection against developing bone stress injury. It also seemed to be associated with a reduction in running related injuries. And so you might think about these repetitive overuse injuries and what are the demands that we're placing on these youth athletes that are still trying to reach peak skeletal maturation, but also don't have the neuromotor control and they don't have the lean tissue, which would allow them to move in ways in which they'd be less likely to be injured. So I think those could be a couple other, you know, key findings that we see, which is, you know, why are we interested in youth runners? Well, you know, I think collectively, we recognize that there is a push towards youth sports specialization. There's a lot of interest in trying to be the best at a sport. And unfortunately, there's a lot of misinformation circulating in the community that's leading individuals to really jump into a single sport at the exclusion of others. And that has some negative effects on both physical and mental health. It really points to the earlier comment that he made Dr. Craback about the large dropout by age 11 in participation in sport. And we need to keep kids in sport and we need to keep them playing and having fun and doing a variety of activities so that they don't develop these overuse injuries that lead to discontinuing sport. And I think there's that interesting component, as we're talking about with growth and development, we sort of mentioned this, that there's this bone mineral content and how the child looks in their peak height velocity. These change in that sort of potentially asynchronous way. So sometimes we make, we'll make assumptions. Well, that kid looks big. So let them go run. They must not have growth plates. And I think that's where we sort of run into trouble, especially with some of this growth and development for this in-between group, these pre-adolescent, adolescent individuals. Dr. Krauss, could you share some of your thoughts? I know you're in a similar realm there. And I guess for you, maybe highlight also kind of one key theme from the research that you tend to relate to patients because we're talking about research and advocacy and what's the knowledge gap that you want us to sort of fill? Yeah, Brian, thanks for having me. I feel like I'm among some legends right here on this panel. So it's just an honor to be here and talk about some areas that I'm pretty passionate about and I'm seeing them in my clinic for sure. And what I found really interesting, an interesting takeaway from the youth running consensus statement was just that there is very strong evidence for female runners, girl runners to be at higher risk than boys. And I think Mike alluded to this. Why is that? Is it more neuromuscular? Is it more hormonal? And one of the other risk factors was delayed menarche or having that first period greater than the age of 15 was a risk factor as well. So I think that just kind of targeting in on these areas as far as a call to action for researchers and just what's coming into my clinic is I see a lot of these athletes kind of in that transitional phase, maybe from middle school to high school, and they're still pre-pubertal, but increasing their training volume. And so I think there's just a real need to break that down. Like exactly why is this female athlete at higher risk? And maybe it is this combination of some weakness in the hips and glutes and their landing patterns. Maybe it's overtraining and sports specialization, but I think there is this low energy availability component to this that we really need to hone in on it and better understand. And Michelle Barrick, she was one of the authors on this consensus statement, and she's an amazing sports dietician. She also does a lot of research on this, and she's been on some great papers with a lot of the panelists. And I think she's just really also trying to understand what type of nutrition recommendations should we be making for these athletes to make sure they're getting enough fuel, enough macro and micronutrients to fuel their body to perform at their best, but also to reduce overall injury risk and allow them to grow and kind of hit these important puberty milestones. And I think a lot of times when I'm in clinic, I'm talking about, we need to dial back the training, dial back or increase the nutrition and fueling and the emphasis on that, and really allow you to hit puberty. And a lot of female athletes, especially I run into, they don't like to hear that because a lot of them are performing really well right now. But as I'm sure you've all seen in your clinic, and I'm sure a lot of people listening have seen, it's at some point something breaks down and that's when it's really heartbreaking for a team, for a coach, for a parent, even just from the physician who's been trying to explain this to the patient for the entire time. So I think really my call to action is to focus biased towards the female athlete and really understand some of these risk factors and the breakdown and how we can really make those changes. So kind of look at prospective studies and it's challenging to study young athletes. You've got to go through a couple of more hoops with consents and asents, but I think it's worth it. And if you get a good program and a good collaborative team effort, it's very doable. Yep. Great. And we're going to explore that a little more in the next section. So hold some thoughts for that, but I want to make sure we get Dr. Harris involved as well. Dr. Harris, we talked a little focus on the bone, but obviously we're not just skeletons running around all over the place with that. Kind of talk a little bit more about some of your assessment for these kids and what you've learned on the consensus statement in regards to the, maybe the non-bone related type of injuries and the conversations you're having with kids and parents and trying to prevent injury. Yeah, totally. Thanks for having me and thanks for putting this together. It's really something truly necessary as you know, how many youth are really, you know, being active in it. So I want to second everything Emily said about energy availability. So it's clearly a key aspect to all bone stress injuries and injury in general. And there's a lot of research on that already that really shows that very clearly. What I really realized after going through this and one of my areas of focus on the consensus statement was really the biomechanical perspective specifically. And there's a total dearth of literature there. There's lots of literature in the adult world on this. And most of it really doesn't pan out very well to say there's one thing more than another. Maybe that's going to happen in youth too, but we really don't have that. And I think that's really where the challenge comes in. I think that's where our call to action is to really work on the biomechanical aspects. Are there areas that we can really focus on? I mean, you mentioned this already. What's the sweet spot between, you know, peak height velocity, that period of rapid growth and peak bone mineralization because that peak height velocity as you alluded to is earlier than where peak bone mineralization, which is a little bit later. So is there a period of transient, you know, bone weakness? So again, going back to bones for a second. So I apologize for that you wanted to talk about other things, but circling back, I mean, two of the biggest risk factors that Mike already mentioned, which is sex, girls, and prior injury are really the two biggest factors for injury in general in youth. And it's not just bone stress injuries, but it's injury in general. So we have to keep that in mind. So I think those are the key things. And why is that sex difference specific? We've already mentioned that, you know, there's probably an energy availability issue, but is there a biomechanical or neuromuscular control issue? And then with regard to the neuromuscular control issue, we all know this already. There's a lot of literature on ACL injury prevention programs, right? I mean, neuromuscular control, there's really nothing at all for runners specifically. And we all focus right on, you know, I learned this from Mike, maybe 20 years ago, running is a sport of balance. And I use that, I use that term all the time with my, with my running patients. You know, you're always on one leg or you're either on either leg when you're in the float phase of running. So you've got to think about running as a sport of balance. That means core and pelvic control is really important. So there probably is something to do with neuromuscular training programs, similar to, similar to ACL injury prevention programs as well, that I think can be really, you know, might be an area of research that really is lacking right now that might be something interesting to do, because we obviously all do it in clinic right now. Think about single leg squats and how, how a runner controls their, their pelvic and core. We just don't have the research to back that up. And I think that's a great point. You know, we, we, we had a really lively discussion a little bit on the, on the biomechanics and, and there's some research that Brian Heiderscheid has done in regards to step break and trying to show how that may impact anterior knee pain and such. But really nothing on kind of a foot strike, although there's some, some things we've learned in the adults that may translate to the kids, but we don't want to treat kids like adults, right? It's important to recognize that they've had. And, and as, as Dr. Harris, Mark, you just talked about, right? Like we, we, we look at, you know, isolated gluteal strength, and then you look at these functional things, but it's really just kind of extrapolating some of the information and there's, there's not much out there. And I would agree. I think that's an exciting area for someone to kind of go out there and think about. And I do, I really like that, that balance proprioceptive component. I really like challenge people, not only in single leg stance, but having them close their eyes just to help them. Like they just wobble like all over the place, you know, even if they have pretty good control, take out that visual component and all of a sudden it changes and it just really helps them understand as well in their rehabilitative process, that, that it's not just about the flexibility and the strength and motion, but it's how it connects to that neuromuscular component to your brain, which I think is really, really helpful in understanding as well. So we do have a question. Thanks for Jack, for bringing that in there. So the question is how much of a mileage week component is there to injury risk? Do high school athletic associates institute any sort of maximal mileage? So, so right. Should we only be running a certain amount? Any volunteers? I have a case study. I have a, I mean, just a nice example. I have a very talented female high school runner. I'm freshmen who isn't, I've seen off and on for the last six months for various aches and pains, very pretty minor. But now she's coming in with fatigue and I asked her about her mileage and she did about between 40 and 50 miles per week, which is she's just been running for about two years now. And she's run all through the pandemic. Hasn't taken any time off kind of tapping into that sports specialization that box. And she's also running the same mileage as her seniors. And the coach isn't, isn't making any distinction between the, between the two. And I think that's really hard for, I think to answer your question, I think it depends on where you go and what region and how experienced the coach is. And sometimes coaches kind of go back based on some more traditional approaches to training, which is high mileage training. And I don't agree with that and that philosophy. And I'm sure a lot of our other panelists may, may agree with me, but I also think it's very dependent on the athlete's experience and their readiness to sport. And I think that in the consensus statement, we talk about that and how, how the guidance and the guidelines and the studies on that are pretty limited, but I do know that there was at least one study that showed that high mileage was a risk factor, extrinsic risk factor. So I'm not going to give you an exact number, but, but I think that, that I do see that especially high mileage and many days per week of running, like seven days a week of running, even six days a week of running is too much for most young adolescent athletes. Yeah. I mean, if you look at the literature, it says, you know, what we found in others is about 30 miles per week. Anything above that does seem to put you at risk for injury. Having said that the kids that we get at Stanford who are recruited here to run are all doing much higher than that. So I think there's certain things you need to look for if, as they progress into the higher mileage, certainly for the women, make sure they're maintaining normal menstrual status. Even with that though, they can still have low energy availability. So keeping an eye on their BMI can be helpful. And then meeting regularly with their pediatrician just to, or, and, and, or a dietician to see if there's any ways that you might improve things. We found that a lot of these athletes were not taking in enough calcium and sometimes it can be very simple. A study that was done in more collegiate, post-collegiate athletes by one of our colleagues, Kristen Siani found that just an extra glass of skim milk a day, didn't even have to be whole milk because a lot of these kids don't want to drink whole milk. Just an extra glass of skim milk a day cut their risk for stress factor by six fold. So sometimes it isn't very dramatic changes that you need to make. Just following up on that in our Stanford kids, we just completed a four-year prospective study to decrease bone stress injuries, which is our most common injury. And these are kids who are just out of their adolescence, right? So 18 to 22. And all we did was try to increase their energy availability. By doing that, we were able to help normalize their menstrual status, improve their bone density, and we significantly cut the rate of bone stress injuries over four years. And the nutrition interventions were not that dramatic. Adding an extra snack or two a day, fueling, making sure they're fueling before they run, right after they run. Yeah. And we're transitioning here to our next topic. So I went ahead and moved it along, but let's continue that conversation. I know from the consensus statement and looking at adolescents and youth runners as well, there's really no great studies to say you should run exactly this number of miles and not more. That's the basic gist of it. You can find guidelines and they really are just people throwing out what they think kids should run. But I think as our speakers have highlighted in regards to the frequency and the buildup and the load that these kids are managing, it varies a little bit by the individual and their design and their other intrinsic and intrinsic factors. But that being said, as Dr. Fredrickson talked about, there's maybe a little bit of guidelines, but the research is still not there. It's a big knowledge gap that we should really try and fill throughout this. Dr. Tenforty or Dr. Harris, any other thoughts on that question of mileage? Yeah, really quickly. I would just like to add to the, I don't know if there's frustration or not, but I would say frustration in that question, because we want to know, right? We want to be able to say, what can we tell our athletes? What can we say? How many miles a week should you be running? Et cetera. And clearly there isn't great guidelines. You look at the literature and there's a number of European studies, right? From the Dutch starting to get people to run programs where they suggest that it's 16 to 20 miles a week or so. And it's couched in kilometers per week. So a lot of Americans may not catch that very well, but it's very minimal mileage to suggest that's the cutoff for when people get injured or not. And clearly that does not help us, right? Because we're treating runners, runners that are in track and cross country and are competitive or running way more than 15, 20 miles a week. So it really is frustrating to not know that good, what's that real pure dose of running. We just don't have it yet. The one final piece I would add is just the concept of training and recovery. So we've talked about nutrition, but the other pieces, the athlete that's running the same volume every week, that's, that's not part of, of training and recovery. You really do need some variability in your micro and macro cycles of training. You need to avoid the mentality that's kind of gone on in the pandemic where you don't have races and a week or two off between seasons. And even then recognizing what a weekend is and having a day off per week completely from running. I think that's really important in young runners. And then really quickly, I'm going to try to get to everyone's questions. There's a real quick question about difference between sprinters and long distance runners. Somebody want to give a kind of one or two minute kind of discussion on that. Well, there are different types of injuries, right? So your sprinters are going to be your more explosive athletes. They're going to be more fast switch types of athletes. Generally, as a general rule, you know, we're less concerned about things related to bone health. That's a very over-generalization, but they tend to get more types of apotheosial injuries. You know, they'll pull off the hamstring, right. Or they'll hip flexor some, because they're doing something much more explosive. So for them, I'm worried more about soft tissue injuries, growth plate injuries. And for them, that's where I think strength training or some type of cross training, it's important for the distance runners, but particularly for those athletes, because I think any strength deficit really comes out. All right. Let's, I know that there's two great questions I actually want to get to, but I want to make sure we're filling in where we're going. We ventured into the area of long term health. Dr. 1040, you talked a little bit about bone health and optimizing and preventing things, bone injuries. Where do we go from here, right? Like, what do we talk to talk about screening and where do we need to go with the research? Because we have a lot of data in sports in general, but again, we're trying to focus on youth running. Where do we, where do we go with this long-term health piece? Yeah. So from, I think we have to kind of talk, break it down by the different topics. I think the first is really just focusing on the basics that we recognize should be overarching for muscle, bone, tendon, ligament recovery, which is nutrition and ensuring adequate energy availability, sleep, which we recognize is, is huge. We, you know, we need to think about variability and training and, and strengthening program. And I, and, and the reason also that I think is worth noting here for this group is that we recognize there are certain tissues that are more vulnerable to low energy availability state and may have a window of opportunity. So so I would say where, where a lot of the research has been, it has been on the topic of bone health, recognizing that your peak bone mass is typically reached by the early third decade of life. So the frustration that, that I've, I've heard from Dr. Fredrickson and experienced myself has been around the college athlete and the young adult athlete who gets injured and you finally start to do the appropriate workup. You look at their their DEXA scan and measurement of their bone quality by bone density as a proxy, and you find their bone density is low. No one's been talking about their nutrition or about maintaining a healthy weight. Menstrual periods have been signed off on, on PPE forms and attributed to some type of an adaptation to training. And, and these are all, we all know that those are not appropriate guidelines. Those are not, those are not, those are not considered normal physiological adaptations. They're actually mal, maladaptive. So from a research standpoint, I think where we're really excited is about the youth runner and finding ways to develop a more robust musculoskeletal system and neuromotor control. I think what we've learned so far from, you know, work that was done by Charles Milgram in, in Israel and the military was reduction in stress fractures of upwards of 84 percent for those that did two or more years of basketball or soccer during a time of puberty. And so looking at young adults, they were much less likely to have a stress fracture during military training, and they were no more protected from developing an injury during military training had they been a runner versus a sedentary individual. Now military medicine is different than running medicine. That's been an interesting conversation with Dr. Milgram that Dr. Fredrickson and I have had, but it does bring up the question, what, what could we potentially study? I'd say one of the, the key features that I, I would propose would be looking at a diversity and sports sampling of physical activity and then getting a more robust long-term outcomes on individuals. So, you know, some key metrics we're interested in are injury prevention in the short term, but in the longer term, we're also interested in keeping these athletes participating in sport over time. So I would say that would be probably one key research target we might have. And, and bone being something that is, you know, again, much more sensitive to, to the time of youth sports participation has been a primary target. Might, might have others in the group also comment perhaps on, on what we understand about joint health and the fact that chondrocytes probably respond very similar to osteocytes to load or tenocytes as, as we expect will also respond to load in terms of proper adaptation. I don't know if one of the other group would like to maybe go into their thoughts about joint health or, or tendon health. Question, right? There's, there's often a question of like, oh, if I run too much mileage, I'm going to get osteoarthritis and be in a wheelchair the rest of my life. So don't run. Dr. Fredrickson, I think you're going to chime in. Well, I just wanted to tag onto that because I think this is so important in terms of what these young athletes are doing at a young age, because not only is it the quality of bone that you're developing it is the, the, the basically the robustness of the bone. So we looked at those who had been primarily runners during their youth versus those who were soccer players. And it was interesting because the runners had a very, and we looked at the tibia as well as their whole body, but it was interesting in the tibia, which is your most common area to get a stress fracture. The runners tibia was very asymmetric, you know, cause they're primarily loading in the sagittal plane. The soccer players had a very robust, very symmetric tibia. In addition, the soccer players had bone density universally high throughout their body. The runners were really no different than sedentary controls. And so I think there's something about, like Dr. Ken Fordy was saying, to really sample different sports, particularly bone loading sports, or to simulate that with some type of exercise program that potentially could be done in PE classes, or jumping activities, where you're loading at more of a higher rate, but also in multi-directions. And so I think this should be more about even general health than even just runners. Let's steer the conversation a little bit about general health. And one of the things we hadn't talked about is mental health and running. And there was a question about sort of this emphasis on increasing energy, preventing injury, yet there are some high-level individuals who have spoken about recurrent stress fractures and the mental health component of being broken down. And especially when we're venturing into this era of name, image, and likeness, where there's a pressure to have a brand, and move forward, and identify yourself quickly, there's a lot of conflicting pressures going on right now. Let's have the panel sort of discuss some of these issues in regards to that pressure, mental health, and disparate stakeholders in regards to trying to get kids running early, and how they're running, and how that's having maybe a negative impact. I would love to chime in on this topic. Kelsey, thanks for bringing up an important question. What about the discrepancy between what we're preaching and what's being practiced at a lot of different levels? And I think my dream is to see more work on really changing that environment and culture at a younger age, and as it pertains to body image, what a runner looks like, and really embracing an athlete, kind of where he or she, or they, show up to that sport, and really being accepting, especially in those early years. I think just really favoring inclusivity. And I think that there's just been just some unfortunate news in the last couple of weeks that is really disappointing about how we're using data in specific ways, and using certain data points, such as body fat percentage to guide training. And I think that really affects athletes even at a younger age, especially as they need that body fat to go through different stages of development. So how do we really encourage embracing kind of that mind-body? And I know that sounds a little bit more woo-woo compared to the tenosites, and the chondrocytes, and just the osteogenic potential of bone, but I think that this is the other piece that is super important to kind of the culture of sport right now. And how do we really encourage athletes to stay in sport, avoid dropping out because they don't look the part, or they're breaking down because they're trying to look the part? And one study that we did during the pandemic was a cross-sectional survey on looking at female athlete triad, and depression, and anxiety symptoms. And we did see a higher association, or greater association of triad risk factors, and depression, and anxiety symptoms, self-reported through a survey. But I think it's really important to just factor that in, that we need to be thinking about this mental health piece when we treat these athletes for these other issues that they come present with. Whether it's a bone stress injury, irregular periods, let's talk about mental health, and maybe the need for maybe providing additional resources for them to see outside of the clinic. Anyone else? Well, I think, and particularly for young women, it's really about changing the culture, because, and having a teenage daughter now, just seeing what she's going through, what they look at on Instagram, and all these social media posts of what they're supposed to look like, as opposed to what's healthy, the messages they're getting are just so dangerous. And I mean, I think it's just, it's a really big issue, and that directly affects their mental health, because when they don't look like that, they get depressed, or they develop eating disorders. So, I mean, it just brings up much, much bigger issues in terms of societal pressures, and how do we change that, and how do we educate, which I know Dr. Krause is really working hard to do. Great. Let's venture a little to this question. I really like this question, because I've been trying to think about a little bit more of the transgender athlete, right? We talked about the sort of mismatch, and velocity, and height, and we've talked about some of the hormonal things. What about that transgender athlete who's going through affirmation? Do we, how do we sort of address running? Is there a concern for running, or the volume they're running? Is there going through things? I really don't know this answer. I'm curious to see what the panel thinks in regards to that question. Yeah, I think there's a lot of silence in the panel, because we just need more, we need more research on transgender athletes. And I think, thankfully, there's been more kind of calls to action, and just some just consensus statements, or just kind of identifying all these gaps, and some of the challenges with these broad recommendations, as far as what a transgender athlete can and can't do. And kind of like I was saying earlier, really favoring and emphasizing inclusivity in sport, and really embracing an athlete for any body type, any sex, gender that they present with, is, I think, really important, especially in a developing athlete, developing their minds, and their body. And as far as risk factors, it's a great question. I think that they're especially, I mean, if they're on certain hormones, and especially hormonal suppression, there should be, I think that should be factored into their training, and their program. And like everything else, thinking about nutrition, and fueling, and micro and macronutrients, and how that hormonal suppression may affect bone health, but I think there's just a lot of gaps in the research right now. And I'm glad we're talking about it, but it's also, I'm humble, and to say, I think, I'm not sure what the best answer is, as far as just general guidelines. Yeah, I mean, I haven't personally dealt with this much in the adolescence, but in, I have seen it, dealt with it in some of our adult athletes. And I, where I get worried, and where I've seen the injuries, is where there is, the hormones are shifting. And I think that's when they are particularly vulnerable to injury. So I would just say, paying close attention, if and when that's occurring. All right. Yeah, I mean, it's a wonderful question. I think, I hope that we, and I imagine we will learn more as we move forward. And I appreciate bringing that up, because I personally have not seen someone, I have a couple of patients who are going through it, and through swimming, which has been an interesting, different area to focus on. But I think it's a great question as well. I'm going to, just for the sake of time, I want to leave a little bit in regards to our appropriateness of running, and ask one last question. We've talked a little bit about these factors in regards to, you've had a prior injury, but what if, there's a question in regards to the well athlete. So here you have someone who's actually kind of like screened, and you're like, hey, you look great. Like, what's the, how are you evaluating that person? What's the value? Maybe take just a couple of minutes here. The value in assessing the person who's actually feels fine, and just wants to go run. Like, how much do we go exploring things, or on the physical exam, or imaging, or other? Yeah, I'll take that to start with, at least. It's a great question, and I think it's one that we need to be really careful with, because there is not one true running form that's best for everyone. There's not one true, as Emily mentioned already, not true one body type that's best for everyone. Clearly, there are things that we think might be better for performance standpoints with regard to running, but with regard to running in general, probably isn't. So I think we need to be really careful about screening people out or in when it comes to that, because the research doesn't really give us that very well. You know, there's some research that shows a leg length discrepancy of, I think, 1.5 centimeters in kids is a risk factor for injury. So those are kind of things that we might think about, but there really isn't that much. So I think the question was about, you know, looking at a dorsiflexion range of motion, and I think you got to be careful with overemphasizing that. I would go back to what I said before, is, you know, running is a sport of balance, and we really got to think about core and pelvic girdle stability first, and then work down the kinetic chain probably after that. I think I don't mean to say that the foot is less important than the spine or the hips, but I think this is the kind of way I approach it specifically. So looking at that single leg balance, looking at single leg squat, then, you know, looking, you know, why can't they squat? Is it because they have tight heel cords, or is it because their glutes are weak, and they just can't get into that 90 degrees of hip flexion? So there's a lot of different things that you can take out from this. So I think that's why the single leg squat is such a great screening tool just for the well runner, because you can take that and look at a few different areas. Great. A few other things for the well runner. The first Dr. Fredrickson had mentioned earlier, which is that there's such a high prevalence of individuals that aren't meeting their calcium and vitamin D recommendations. We also found in the middle school aged runners that a number were skipping meals or breakfast, or even using unhealthy dieting patterns such as, you know, taking, you know, taking, you know, diuretics. So more than anything, it's just a reminder of, you know, the basics about, about nutrition, about sleep, about, you know, just getting three square meals a day, and just having fun. And I think those are key elements to communicate. And then in the female athlete, as mentioned earlier, it's just about menstrual health. And I like to frame that as a female athlete vital sign. And so just to communicate that to the young woman, so she knows that if her period is becoming irregular, or stopping with heavier training, that's a time where it might make sense to check in with a sports medicine provider, maybe meet with a sports dietician, someone who can just ensure that there isn't anything else going on and keep them on track with the nutritional strategies, so they develop healthy behaviors around that. Let me add on to something about nutrition, because I found this kind of fascinating and interesting, I think it's very practical for us to just take away. So there's some literature to suggest that high school runners specifically, so girls and boys are generally undernourished with regard to how many kilocalories they take in per day. And I think the number was that, again, this is all covers, right? So it's got to be careful with, you know, emphasizing that girl runners taking about 2000 calories a day, and they're probably depending on body type, etc, and exercise about 2,528 calories a day. And then males about 2,500 to 3,000 calories a day is what they usually take, but their needs are probably 3,100 to 3,600 a day. So there really is does seem to be a deficit just overall. And I think that's something that we need to watch out for as, you know, practitioners that care for these patients, as well as parents ourselves, and as well as friends of parents. Just to be thinking about it, I think that's one easy, relatively easy thing I'll say, because it's really hard to get a calorie count on a kid, I think, but relatively easy thing to be thinking about with regard to, you know, some of these risk factors and nutrition. Get a feel for what your kid's really eating. Yeah, and I'd say three square meals and two to three good snacks per day for a runner during training. Yeah, which I know it's so easy to just tell an athlete and they're like, oh, I only get one snack and I don't even have any food between lunch and practice. And of course, no wonder they're underperforming and under-fueled. So that's an easy, low-hanging fruit. Yeah. All right. I'm going to pivot us to the last session. We could go on and on and on, but we got about five minutes left and I want to leave a little moment for everybody to comment. So the last area we're talking about appropriateness of running as a sport, and pretty much there's, as we've alluded to, there's really not research that we think running's important, but exactly when in the mileage is not. What I'm going to ask the panel to do, I want you to sort of discuss this topic of appropriateness for running as it relates to the able-bodied and disabled athlete, because there was someone had brought up a question about those athletes with disabilities. So when can these kids start running? Dr. Harris, what is your advice? So you're a year old and wants to run a marathon. Yeah, I'll come back to what you said before. So there isn't, to be very clear, there isn't clear evidence that distance running is bad for youth. We know that. And there is some limited evidence that distance running is okay. And that comes from some of the marathon studies, like the LA Marathon specifically, and seeing these large cohort, like 2000 a year of kids that are training from middle school through high school. And there was data to suggest that those kids were less injured than adults that run marathons, actually, which is really fascinating. So it kind of turns something over in our heads with regard to maybe it isn't so bad that kids run long distances. Now, when we go back to before, it's not all about chronologic age. It's about biologic age and what their factors are with regard to how developed they are and how much mileage they can handle. I think two key things, one is internal motivation is key. So if it's the internal motivation of the youth, the youth, the kid wants to run, that's key. It's not the parent wants them to run. The parent wants to be a runner just like I am. It's not that the coach wants to be a runner, but it's the kid. That's key, first of all. And some of that's hard to kind of discern, especially on that first office visit if we're a physician seeing a patient. That's really key. And then the second is an organized running program. And that's what the LA Marathon really showed us very well. The LA Marathon Corps really showed us really well is that having an organized training program is probably better than just having some kid run on their own and just be coached by one person or by their parents to just kind of get faster and faster so they can run their 5k at the best time by the time they're 10 years old or so. So I think those are key factors, internal motivation and then organized programs. Yep. I like to say like child directed, adult protected is the phrase I use. Let it be driven by the child. All right, someone else. I see Dr. I think I cut off Dr. Fredrickson earlier. So what do you got to say on this topic? Well, on this topic, I would say, I mean, I think running is a great activity. I think as long as it is driven by the kid. But I would say in terms of just light running, but where I get concerned is the kid who gets really serious about it. And that's all they're focusing on to the exclusion of any other types of sport activities or cross training activities. And even though they might be able to do marathons and they're not getting injured at that time, I just have seen these kids after another, they flame out later in life. So I tell the coaches when I lecture to USA Track and Field, I say, if you want these kids to be really good runners later on in life, even if they're doing great early on, get them going with other sports because otherwise they will burn out and they will get injuries later in life, I guarantee it. And just one other point, just to add on what Mark was saying about the single leg squat, just real quick. Great thing for screening. I would just say too, that looking for imbalances in muscle strength or flexibility, we do this in our Run Safe program because running is a very symmetric sport. And this is an area where I think we need further research, but we see it when they come in with injuries, invariably there's some type of muscle imbalance. So I would just be careful to screen for that. Okay. We got a few more minutes. I'm going to ask Dr. Kraus and Dr. Tenforty to just comment on this appropriateness of running. Yeah, I think if you emphasize fun, you mix it up. I mean, these kids are, I love the idea of like an open field. I mean, this is the picture and it's hard to put kind of reign in a kid who just really wants to run. And I think encouraging recovery, sleep, understanding that they may not be able to manage heat, thermoregulation, and they're just like hunger cues. So encouraging, taking breaks for snacks. It's always fun. Everybody loves snacks, but sometimes they forget about snacks because they love running so much. So mixing it up and especially around here on the West coast, I mean, these kids are running all year round, so they have that ability. So I think just reemphasizing what Dr. Fredrickson said about really encouraging diversification in sport early on, especially in running. Dr. Tenforty, thank you. Yeah, I agree with all the panelists. I think, you know, the one final thing to keep in mind is that, you know, we're trying to help advise not just the youth athlete, but also the family, the entourage around them, and just making sure that we're setting good examples in terms of eating, in terms of exercising, and just making sure they're having fun with sport. I mean, this is, you know, youth running is supposed to be fun, and it's supposed to be an activity you can enjoy your entire life, and it's a fundamental, you know, movement of all land-based sports. So just to recognize, you know, the value of being able to run, and then to make sure that it's something that's just a fun activity that the kid really kind of drives what's being done, but the parents also provide a good model, just as you had mentioned, Dr. Pivack. Great, and with that, it's hard to believe our hour is pretty much up, so I want to thank all of the panel. I want to thank everyone who's provided questions. I think there's hopefully a walk away with a little better understanding of maybe how to approach the youth athlete. Encourage those of you in regards to advocacy and research. I think we have some knowledge gaps that we really need to fill and hope to add in regards to our next revision of the consensus statement. I want to thank everyone for all their hard work in regards to trying to promote our understanding of the youth athlete, and with that, have a wonderful day. Right on the minute, like seconds to spare. That's a swimming thing.

youth running

consensus statement

injury prevention

health promotion

exercise benefits

sports dropout

risk factors

running kinematics

nutrition for young runners